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CPT_99252_Template

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99252 INPATIENT CONSULTATION DOCUMENTATION TEMPLATE

CPT Code 99252: Initial Inpatient Consultation - Low Complexity

Code Level: Low complexity E/M for consult patients
Typical Time: 20-29 minutes total encounter time
2025 Medicare Reimbursement: $89.34 Requirement Method: Time-based OR Low-Complexity MDM (choose one)

DOCUMENTATION CHECKLIST

HISTORY (H) - Problem-Focused

Required elements for this level:

  • Chief Complaint: Stated reason for consultation (1-2 lines)
  • HPI: Problem-focused history of present illness
    • Brief description of current problem
    • Duration (when did this start?)
    • Relevant context for THIS consultation request
    • Do NOT need extensive detail—focus on why consult was called
  • ROS: Problem-focused review of systems
    • Document at least 1-3 systems relevant to chief complaint
    • Can state “ROS reviewed and unremarkable” for others
  • PMH: Past Medical History (brief list relevant to problem)
  • PSH: Past Surgical History (if relevant)
  • Medications: Current list
  • Allergies: Documented
  • Social History: Brief, relevant to consult

Documentation Tip: Think “focused on the reason for consultation,” not comprehensive.

PHYSICAL EXAM (E) - Problem-Focused

Required elements for this level:

  • Vital Signs: Temperature, HR, BP, RR, O₂ sat (document current)
  • General: Brief assessment (alert, comfortable, distressed, etc.)
  • Focused Systems: Examine only systems relevant to chief complaint
    • Examples:
      • Consult for chest pain → Heart, lungs, abdomen
      • Consult for UTI symptoms → Abdomen, GU exam, CVA tenderness
      • Consult for orthopedic issue → Affected extremity, ROM, strength
  • Abnormal Findings: Document clearly if present
  • Normal Findings: Can be brief or summarized (e.g., “Abdomen soft, non-tender”)

Documentation Tip: “Problem-focused” means examine what’s relevant to the problem, not a full head-to-toe.

MEDICAL DECISION-MAKING (MDM) - Low Complexity

For 99252, document evidence of LOW complexity:

Problem Count & Complexity:

  • 1-2 problems addressed (not extensive list)
  • Problems are typically uncomplicated or new to the consulting specialty

Amount & Complexity of Data Reviewed:

  • Limited data reviewed (1-2 sources)
    • Examples:
      • Review of prior labs or imaging already done
      • Physical exam findings documented here
      • Patient/family history reported
  • Do NOT require extensive workup ordering

Risk of Complications/Morbidity & Mortality:

  • Low Risk: Condition is not life-threatening, minimal risk of serious complication
    • Examples:
      • Follow-up for stable pneumonia (already diagnosed, on antibiotics)
      • Consult for medication adjustment in stable patient
      • Evaluation for mild dehydration with IV fluids planned

MDM Documentation Language:

EXAMPLE 1 (Low):
"Patient with known UTI, currently on antibiotics. Exam consistent 
with mild hydration deficit. Recommend increasing fluids and 
continuing current antibiotic course. No systemic toxicity."

EXAMPLE 2 (Low):
"Referred for evaluation of mild anemia. Labs show Hgb 9.2, iron 
studies pending. No acute bleeding. Recommend oral iron supplementation 
and recheck CBC in 4 weeks."

EXAMPLE 3 (Low):
"Post-op day 2 from routine surgery. Mild pain, well-controlled 
on current regimen. Incision clean and dry. Plan to continue 
pain management as prescribed."

MEDICAL DECISION-MAKING FRAMEWORK

99252 = LOW Complexity

2 of 3 categories below = LOW:

CategoryLowModerateHigh
Problem1-2 self-limited or minor1-2 established w/ workup3+ established or acute/complex
DataLimited (1-2 sources)Moderate (3-4 sources)Extensive (5+ sources)
RiskMinimal/LowModerateHigh

For 99252: Ensure 2 of 3 fall into the “Low” column.

ASSESSMENT & PLAN

Assessment

  • Summary statement of consultation findings
  • Incorporate chief complaint + key exam findings + most relevant history
  • Example: 
    68-year-old male admitted with pneumonia, referred for ID consult. 
Currently afebrile on day 2 of antibiotics. Exam shows decreased 
breath sounds left base, otherwise well-appearing. Imaging consistent 
with left lower lobe infiltrate.

Plan

  • Recommendation(s): What specialty recommends going forward
    • Continue current therapy? Adjust? Add? Change?
    • What specific interventions or follow-up?
  • Timeline: When will patient be re-evaluated?
  • Communication: State that you discussed with primary team/patient
  • Example: 
    PLAN:
1. Continue current antibiotic regimen (appropriate for pneumonia)
2. Encourage ambulation and breathing exercises
3. Recheck CXR in 48 hours
4. Will follow along during hospitalization
5. Discussed recommendations with primary team and patient

DOCUMENTATION EXAMPLES (Real-World Scenarios)

Scenario 1: Post-Op Orthopedic Consult (99252)

PATIENT: 72-year-old female, POD#2 after total knee replacement

HPI: Referred by surgical team for management of post-operative pain. Patient reports pain 6/10 at rest, 8/10 with PT. Started on IV morphine yesterday, currently on 2mg Q4H. She is alert and oriented, denies nausea.

ROS: Patient denies fever, shortness of breath, chest pain. No GI symptoms. Able to use bedside commode.

PMH: HTN, Type 2 DM, OA

PSH: Prior gallbladder removal 10 years ago; this TKR is first orthopedic surgery

Meds: Lisinopril, Metformin, Morphine IV

Allergy: NKDA

Social: Lives with daughter, non-smoker

PHYSICAL EXAM:

Vitals: T 37.1°C, HR 88, BP 132/78, RR 16, O₂ sat 96% RA

General: Alert, oriented x3, mildly uncomfortable

Extremity (surgical): Left knee dressing clean and dry. Minimal swelling. No drainage. Incision edges intact. Good capillary refill toes. Pedal pulses intact. Pain with range of motion.

Other: No evidence of DVT in lower extremities. No calf tenderness or swelling.

ASSESSMENT:

72-year-old post-op patient from TKR, POD#2, with expected post-operative pain. Currently on IV morphine with moderate relief. No complications noted on exam. Surgical site healing appropriately.

PLAN:

  1. Continue current pain regimen (morphine 2mg IV Q4H)
  2. Consider transition to oral pain management (e.g., oxycodone) once tolerating PO diet (likely tomorrow)
  3. Encourage PT/ambulation as tolerated for mobilization and recovery
  4. Monitor for signs of DVT or bleeding
  5. Will re-assess daily during hospitalization
  6. Discussed plan with patient and surgical team

Scenario 2: Psychiatry Consult for Anxiety (99252)

PATIENT: 55-year-old male admitted with pneumonia, anxious

HPI: Hospitalized 2 days ago with pneumonia. Since admission, patient reports increasing anxiety, difficulty sleeping, and worry about illness severity. No prior psychiatric history. Denies suicidal/homicidal ideation. Currently on O₂ and antibiotics, respiratory status stable.

ROS: Denies hallucinations, delusions. Reports difficulty concentrating due to worry.

PMH: Hypertension, well-controlled. No psychiatric history.

PSH: Appendectomy 20 years ago

Meds: Lisinopril, amoxicillin-clavulanate, acetaminophen

Allergy: NKDA

Social: Married, works in finance. Non-smoker.

PHYSICAL EXAM:

Vitals: T 37.2°C, HR 82, BP 128/75, RR 15, O₂ sat 97% on 2L

General: Alert, oriented x3. Appears anxious, fidgeting with hands.

Mental Status: Mood anxious. Affect appropriate to mood. Thought process logical. Denies SI/HI.

Other: No tremor noted.

ASSESSMENT:

55-year-old with acute anxiety related to hospitalization for pneumonia. No prior psychiatric history. Respiratory status stable which reduces some acute stressors. Currently coping with normal worry given acute illness.

PLAN:

  1. Start lorazepam 0.5mg PO Q6H PRN for anxiety
  2. Encourage relaxation techniques and reassurance by nursing staff
  3. Explain respiratory status is improving to reduce worry
  4. Monitor for worsening anxiety or new psychiatric symptoms
  5. Plan for discontinuation of anxiolytic prior to discharge if pneumonia resolves as expected
  6. Discussed plan with patient and primary team

Scenario 3: Nephrology Consult for Acute Kidney Injury (99252)

PATIENT: 64-year-old female admitted with sepsis, AKI stage 1

HPI: Admitted yesterday with urosepsis from UTI. Currently on IV fluids and broad-spectrum antibiotics. Creatinine rose from baseline 1.0 to 1.4. UOP adequate. Patient is afebrile today on antibiotics.

ROS: Denies dysuria, flank pain. No prior kidney disease history. Denies edema.

PMH: HTN, prior UTI (uncomplicated)

PSH: Hysterectomy 15 years ago

Meds: Hydrochlorothiazide, ceftriaxone, gentamicin

Allergy: Sulfa drugs

Social: Lives alone, retired teacher

PHYSICAL EXAM:

Vitals: T 36.8°C, HR 76, BP 124/70, RR 14, O₂ sat 98% RA

General: Alert, comfortable

Abdomen: Soft, non-tender, no CVA tenderness

Extremities: No edema

Lungs: Clear to auscultation bilaterally

ASSESSMENT:

64-year-old with stage 1 AKI secondary to sepsis from UTI. Creatinine minimally elevated at 1.4. Urine output appropriate. Responding well to fluid resuscitation and antibiotics. Prognosis for recovery expected.

PLAN:

  1. Continue IV fluid resuscitation with careful monitoring of I&Os
  2. Monitor creatinine and electrolytes daily
  3. Continue current antibiotic regimen
  4. Avoid nephrotoxic agents (will flag NSAID use)
  5. May transition to oral antibiotics once stable
  6. Expect creatinine to normalize as sepsis resolves
  7. Will follow daily during hospitalization
  8. Discussed plan with patient and primary team

COMPLIANCE REMINDERS & RED FLAGS

✅ What Gets You Paid (99252 Defensible):

  • Focused HPI tied to reason for consult ✓
  • Problem-focused exam matching HPI ✓
  • Low MDM with 2 of 3 categories LOW ✓
  • Clear recommendation(s) from specialty ✓
  • Specific timeline for re-assessment ✓
  • Communication documented (discussed with team) ✓
  • Time 20-29 min (if billing by time) ✓

🚨 Red Flags (Audit Risk):

Red FlagWhy It’s a ProblemHow to Fix
Generic language”Consulted. Recommend continue current care.”Document SPECIFIC findings + SPECIFIC recommendations
Copying from admission noteAuditor sees identical text → not consultation workUse your own words, focus on specialty perspective
No exam findingsCan’t justify problem-focused if nothing documentedDocument at least 3-4 relevant systems
Vague MDM”Complex case” without explaining whyDefine what makes it complex (or in this case, why it’s LOW)
No follow-up planConsult seems incompleteState: “Will follow during hospitalization” or “Re-assess in 24 hours”
Billing 99252 for complex caseOver-simplifying documentationIf genuinely complex, bill 99254 or 99255 instead
Multiple consults same dayEach needs separate documentationDon’t lump into one note

TIME DOCUMENTATION (If Using Time-Based Billing)

99252 requires: 20-29 minutes of time documented

Example Time Entry:

Time spent: 08:15 - 08:38 (23 minutes)
  - 5 min: Review admission note and labs
  - 8 min: History and focused exam
  - 7 min: Assessment and formulation of recommendations
  - 3 min: Documentation

QUICK REFERENCE: 99252 vs OTHER CONSULT CODES

CodeTimeMDMWhen to Use
9925115-19 minProblem-focusedDELETED (2023) - Do not use
9925220-29 minLowSimple consult with minor/stable issue
9925330-39 minModerateModerate complexity, some workup
9925440-54 minModerate-HighComplex case, significant workup
9925555+ minHighHigh complexity, extensive data, high risk

AUDIT DEFENSE CHECKLIST

Before submitting claim for 99252, verify:

  • This is clearly a CONSULTATION (requested by another service)
  • History is problem-focused (brief, relevant to consult reason)
  • Physical exam is problem-focused (not comprehensive)
  • MDM is LOW complexity (2 of 3 categories low)
  • Recommendation is specific and actionable
  • Follow-up plan documented (will re-assess when?)
  • Note documents discussion with requesting provider/patient
  • Time documented (20-29 min) if using time-based method
  • Avoiding 99252 for genuinely complex cases (that need 99254+)

FACILITY DOCUMENTATION STANDARDS

Use this section to customize for your organization:

  • Your Facility’s Consult Request Process: ________________________
  • Expected Turnaround Time: ________________________
  • Who Receives Consult Report (besides EHR)? ________________________
  • Your Facility’s MDM Definition: ________________________
  • Payer Mix (Medicare %, Commercial %, Other): ________________________
  • Any Bundling Rules to Watch For: ________________________
  • Required Elements Per Your Compliance Officer: ________________________

BILLING NOTES & MODIFIERS

Typical Modifiers Used with 99252:

  • 25 (Significant, Separately Identifiable Service): If same day as procedure, use Mod 25
  • -59 (Distinct Procedural Service): If bundling concerns exist
  • -26 (Professional Component): If billing interpretation only
  • -TC (Technical Component): If billing technical portion only

COMMON PITFALLS & SOLUTIONS

Pitfall 1: Copying Admission Note Word-For-Word

Problem: Auditor sees identical documentation → No specialty consultation work evident Solution: Use your own words. Focus on specialty perspective and what your specialty contributes.

Pitfall 2: Documenting 99254 Complexity but Billing 99252

Problem: MDM clearly shows moderate-to-high complexity → Under-coding Solution: Bill appropriate code that matches documented complexity. Better to bill 99254 defensibly than 99252 questionably.

Pitfall 3: No Clear Recommendation

Problem: “Consult completed” without actionable plan Solution: State specific recommendations: “Continue current antibiotics,” “Add iron supplementation,” “Increase physical therapy,” etc.

Pitfall 4: Forgetting Follow-Up Statement

Problem: Consult seems abandoned Solution: Always state: “Will follow during hospitalization,” “Re-assess in 24 hours,” or “Discharge planning will incorporate recommendations”

REAL-WORLD DOCUMENTATION TIPS

For Speed Without Sacrificing Quality:

  1. Use templates → Saves time, ensures consistency
  2. Abbreviations → HR, BP, RR, O₂ sat, etc. (use standard facility abbreviations)
  3. Problem-focused language → “Exam notable for…” or “Exam unremarkable except…”
  4. Copy forward carefully → Only copy elements that truly apply today
  5. Pre-chart → Before seeing patient, review prior notes and labs
  6. Sign off quickly → Don’t over-edit; if it’s accurate, submit

REIMBURSEMENT INFO

2025 Medicare Rate: $89.34 [web:115][web:121][web:122]

Facility vs. Professional:

  • Facilities receive different rate (typically ~45% of professional fee)
  • Professional rate shown here applies to individual providers

Payer-Specific Rules:

  • Some commercial payers still pay consultation codes
  • Some have shifted to office visit codes
  • Always verify YOUR payers before billing

MONTHLY AUDIT TEMPLATE (Self-Check)

Review 5 recent 99252 consults you coded:

DatePatientRequesting ServiceMDM LevelAppropriate?Notes
Low/Mod/High[ ] Yes [ ] No
Low/Mod/High[ ] Yes [ ] No
Low/Mod/High[ ] Yes [ ] No
Low/Mod/High[ ] Yes [ ] No
Low/Mod/High[ ] Yes [ ] No

Accuracy Rate: ___/5 (Goal: 100%)

FINAL TIPS FOR SUCCESS

From your perspective as a medical coder:

  1. You know complexity when you see it - Don’t force simple cases into high codes
  2. You know what auditors look for - Specific findings, clear recommendations, documented follow-up
  3. You know your facility’s patterns - Use these to identify under/over-coding
  4. You know the difference between a consult and a regular visit
  5. You know compliance matters - Better to bill one level lower confidently than one level higher questionably

NEXT STEPS

  1. Save this template to your Obsidian folder
  2. Customize the “Facility Documentation Standards” section with your specific rules
  3. Review the 3 scenarios - use as reference during actual consults
  4. Print the Audit Defense Checklist - keep at desk
  5. Run through 3 recent consults using this template to verify alignment
  6. Update your facility’s consult documentation protocol with 99252 specifics

CONGRATULATIONS! 🎉

You now have a complete, audit-ready documentation template for 99252 inpatient consultations.

Use it well. Document specifically. Defend confidently.

Document Created: February 2026 Last Updated: February 2026 Compliant with: 2021 AMA E/M Guidelines, CMS Standards, Current Consultation Coding Rules (99251 Deleted)

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